Recommendations for empiric antimicrobial therapy for purulent meningitis based on patient age and specific predisposing condition*
|
Predisposing factor |
Common bacterial pathogens |
Antimicrobial therapy |
|
Age |
||
|
<1 month |
Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes |
Ampicillin plus cefotaxime; OR ampicillin plus an aminoglycoside |
|
1 to 23 months |
Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli |
Vancomycin plus a third-generation cephalosporin¶Δ◊ |
|
2 to 50 years |
N. meningitidis, S. pneumoniae |
Vancomycin plus a third-generation cephalosporin¶Δ◊ |
|
>50 years |
S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli |
Vancomycin plus ampicillin plus a third-generation cephalosporin¶Δ |
|
Head trauma |
||
|
Basilar skull fracture |
S. pneumoniae, H. influenzae, group A beta-hemolytic streptococci |
Vancomycin plus a third-generation cephalosporin¶Δ |
|
Penetrating trauma |
Staphylococcus aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), aerobic gram-negative bacilli (including Pseudomonas aeruginosa) |
Vancomycin plus cefepime; OR vancomycin plus ceftazidime; OR vancomycin plus meropenem |
|
Postneurosurgery |
Aerobic gram-negative bacilli (including P. aeruginosa), S. aureus, coagulase-negative staphylococci (especially S. epidermidis) |
Vancomycin plus cefepime; OR vancomycin plus ceftazidime; OR vancomycin plus meropenem |
|
Immunocompromised state |
S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli (including P. aeruginosa) |
Vancomycin plus ampicillin plus cefepime; OR vancomycin plus meropenem§ |
* For recommended dosages for adults, refer to the UpToDate table on recommended intravenous dosages of antimicrobial therapy for adults with bacterial meningitis.
¶ Ceftriaxone or cefotaxime.
Δ Some experts would add rifampin if dexamethasone is also given.
◊ Add ampicillin if meningitis caused by Listeria monocytogenes is suspected.
§ Meropenem provides sufficient coverage for Listeria when used as part of an initial regimen. However, if Listeria is identified, the patient should generally be switched to a regimen that includes ampicillin. Refer to the UpToDate topic that discusses treatment of Listeria for a discussion of regimen selection.
Modified with permission from: Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267. Copyright © 2004 University of Chicago Press.
Recommended intravenous dosages of antimicrobial therapy for adults with bacterial meningitis who have normal renal and hepatic function
|
Antimicrobial agent |
Dose (adult) |
|
Amikacin |
5 mg/kg every 8 hours* |
|
Ampicillin |
2 g every 4 hours |
|
Aztreonam |
2 g every 6 to 8 hours |
|
Cefepime |
2 g every 8 hours |
|
Cefotaxime |
2 g every 4 to 6 hours |
|
Ceftazidime |
2 g every 8 hours |
|
Ceftriaxone |
2 g every 12 hours |
|
Chloramphenicol |
1 to 1.5 g every 6 hours¶ |
|
Ciprofloxacin |
400 mg every 8 to 12 hours |
|
Gentamicin |
1.7 mg/kg every 8 hours* |
|
Meropenem |
2 g every 8 hours |
|
Moxifloxacin |
400 mg every 24 hoursΔ |
|
Nafcillin |
2 g IV every 4 hours |
|
Oxacillin |
2 g IV every 4 hours |
|
Penicillin G potassium |
4 million units every 4 hours |
|
Rifampin |
600 mg every 24 hours◊ |
|
Tobramycin |
1.7 mg/kg every 8 hours* |
|
Trimethoprim-sulfamethoxazole (cotrimoxazole) |
5 mg/kg every 8 hours§¥ |
|
Vancomycin |
15 to 20 mg/kg every 8 to 12 hours‡ |
IV: intravenously; MRSA: methicillin-resistant Staphylococcus aureus.
* Dose based on ideal body weight or dosing weight except in underweight patients. A calculator for ideal body weight and dosing weight is available in UpToDate. Dosage and interval must be individualized to produce a peak serum concentration of 7 to 9 mg/L and trough <1 to 2 mg/L for gentamicin or tobramycin and a peak of 25 to 40 mg/L and trough <4 to 8 mg/L for amikacin. For additional information, refer to the UpToDate topic on aminoglycosides.
¶ The higher dose is recommended for patients with pneumococcal meningitis.
Δ No data on optimal dosage needed in patients with bacterial meningitis.
◊ For the treatment of MRSA meningitis, the Infectious Diseases Society of America (IDSA) suggests a rifampin dose of 600 mg orally once daily or 300 to 450 mg twice daily.[1]
§ Dosage is based on the trimethoprim component.
¥ We administer trimethoprim-sulfamethoxazole at a dose of 5 mg/kg (based on the trimethoprim component) IV every 8 hours in patients with normal renal function. However, there are limited data on the preferred dosing interval, and in case reports, the dose of trimethoprim-sulfamethoxazole has been administered anywhere from every 6 to every 12 hours. For the treatment of MRSA meningitis, the IDSA suggests a trimethoprim-sulfamethoxazole dose of 5 mg/kg (based on the trimethoprim component) intravenously twice or three times daily.[1]
‡ The vancomycin dose should not exceed 2 g per dose or a total daily dose of 60 mg/kg. Adjust dose to achieve vancomycin serum trough concentrations of 15 to 20 mcg/mL.[1]
Reference:
Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children: Executive Summary. Clin Infect Dis 2011; 52:285.
Modified with permission from: Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267. Copyright © 2004 University of Chicago Press.
리스테리아 모노사이토게네스(Listeria monocytogenes)는 세균성 뇌수막염에서 차지하는 비율은 적지만, 나이가 증가할수록 발생률이 증가합니다. 이와 같은 이유로 50세 초과 성인에서 세균성 뇌수막염에 대한 empiric regimen에는 L. monocytogenes에 대한 항생제(예, ampicillin)가 포함되어 있습니다.
In a United States surveillance study performed by the Centers for Disease Control and Prevention via the Emerging Infections Program Network, between 2003 and 2007, 1083 cases of bacterial meningitis were reported in adults; S. pneumoniae was responsible for 71 percent of cases, Neisseria meningitidis for 12 percent, group B Streptococcus for 7 percent, Haemophilus influenzae for 6 percent, and Listeria monocytogenes for 4 percent. Importantly, in adults, the incidence of bacterial meningitis caused by L. monocytogenes rises with increasing age. For this reason, adults >50 years of age should receive an antimicrobial agent with activity against L. monocytogenes (eg, ampicillin) as part of the empiric regimen.
Ampicillin과 penicillin G는 listeriosis의 DOC입니다. Ampicillin과 penicillin G는 CSF에서 이룰 수 있는 농도에서 delayed in vitro bactericidal activity를 나타냅니다. 그 결과 우리는 보통 listerial CNS infections, endocarditis, 신생아와 면역 억제 환자의 감염에서 bacteriocidal인 gentamicin 항생제를 synergy를 위해 병합하여 사용합니다.
Ampicillin or penicillin G is the drug of choice for listeriosis. Although no controlled trials have been published, Listeria are similarly susceptible in vitro to these antimicrobial agents, and acquired resistance to the most commonly used drugs is rare . Ampicillin and penicillin G demonstrate delayed in vitro bactericidal activity at concentrations attainable in the cerebrospinal fluid (CSF). As a result, we usually treat listerial CNS infections, endocarditis, and infections in neonates and immunocompromised patients with combination therapy, with the bactericidal agent gentamicin being added to ampicillin or penicillin to achieve synergy.
Regimens without aminoglycosides may be preferable for patients who have impaired renal function or are taking other nephrotoxic drugs, such as cyclosporine.
The data to support specific antimicrobial regimens come from observational studies. In the MONALISA study, a nationwide prospective cohort study in France, on multivariate analysis, the use of active beta-lactam therapy (eg, amoxicillin, which is available in an intravenous [IV] formulation in Europe), trimethoprim-sulfamethozaxole (TMP-SMX), and aminoglycoside use were associated with reduced three-month mortality (odds ratio [OR] for active beta-lactam: 0.10, 95% CI 0.04-0.26; OR for TMP-SMX: 0.49, 95% CI 0.26-0.92; OR for aminoglycoside: 0.60, 95% CI 0.38-0.94)
REF. UpToDate 2019.05.06
